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Stress and its impact on periodontal health

Patients with high stress can have a higher risk of developing periodontal diseases. Read the article to know more.

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Stress: one of the determining factors of periodontal disease

Periodontal diseases are multifactorial, which is caused due to a destructive inflammatory process affecting tooth‑supporting tissues that induce elevation of pro‑inflammatory cytokines, resulting in tissue destruction. There are several local or systemic risk factors which influence the progression of the periodontal disease, with the dental plaque being a primary etiologic factor harbouring specific periodontal pathogens.1

Prevalence of stress-induced periodontal disease

A systematic review assessed Fourteen articles (seven case-control studies, six cross-sectional studies, and one prospective clinical trial) for determining the relation between stress and periodontal disease.2

  • 57.1% of patients showed a positive outcome between psychosocial factors/stress and periodontal disease2
  • 28.5% observed a positive outcome for some characteristics and a negative outcome for others2
  • Patients with stress related to economic problems (72.7%), work tension (61%), job insecurity (27.3%) showed a higher incidence of periodontal diseases.3

How does stress cause periodontal disease?

Stress is a dynamic and interactional process of intricate systems with formulations and operationalization of the components at various levels. Chronic stress has a net negative effect on the efficacy of the immune response, leading to an imbalance between host and parasites, and consequently resulting in the periodontal breakdown. For necrotizing periodontitis, stress has been shown to represent a secondary aetiological factor.4

Figure 1: Effect of stress on periodontal disease

Figure 1: Effect of stress on periodontal disease

Stress and periodontal disease: the mechanism

There are several studies which show that major negative life events more dependably occur in close proximity to the onset or exacerbation of illness, and the relationship between important negative life events and disease was mediated by the immune system. Research has also shown that emotional stress can modulate the immune system through the neural and endocrine systems in at least three different ways:5

  1. Through the autonomic nervous system pathways
  2. Through the release of neuropeptides
  3. Through the release of hypothalamic and pituitary hormones.

Stress and the immune system

Stress activates the hypothalamic-pituitary-adrenal axis resulting in the secretion of corticotropin-releasing hormone and vasopressin by the hypothalamus. This acts on the pituitary gland, which in response, secretes the pituitary corticotropic hormones to act on the adrenal cortex and increase the production and release of cortisol and glucocorticoid hormones. They are essential for a long-term stress response. Glucocorticoids modify the behaviour of lymphocytes, macrophages, and monocytes by inducing a decrease in immunocompetence. Overtime they contribute to the risk of cardiovascular disease, diabetes mellitus, rheumatoid arthritis, and other diseases.6

This decrease in immunocompetence occurs because of the following: 6

  • Changes to the inflammatory response;
  • Inhibition of IgA, IgG, and neutrophil function that leads to an increase in bacterial colonization of the biofilm and a decrease in the ability to prevent connective tissue invasion;
  • Changes to the initial cytokine profile in place of interleukin-1 and TNF α;
  • Elevated blood glucose levels;
  • A change in the rates of certain growth factors.

A prolonged period of chronic cortisol elevation and the immune dysfunction leads to the deregulation of the inflammatory inhibitory abilities, thereby promoting chronic inflammatory damage within the periodontium. 6   

Figure 2: Mechanisms linking maladaptive stress coping and progression of periodontal diseases

Figure 2: Mechanisms linking maladaptive stress coping and progression of periodontal diseases

Stress and alteration in salivary flow

Both increase and decrease in salivary flow, induced by emotional disturbance, can affect the periodontium in several ways. Emotional distress can change the saliva pH and chemical composition like IgA secretion. The decrease in saliva production can result in an increase in the number of pathogens in the oral cavity.5

Stress and behavioural changes

Several studies and reports have shown that stress not only decreases the frequency as well as the quality of the dental hygiene but also the increase of tobacco use and alcohol consumption and changes the food habits which leads to a lowering of general health.5,6


Patients with high stress can have a higher risk of developing periodontal diseases. Care should be taken to keep the stress level in check and to maintain a good oral hygiene.



  1. Penmetsa G, et al. Effect of stress, depression, and anxiety over periodontal health indicators among health professional students. Journal of Indian Association of Public Health Dentistry. 2019;17(1):36.
  2. Peruzzo D, et al. A Systematic Review of Stress and Psychological Factors as Possible Risk Factors for Periodontal Disease. Journal of Periodontology. 2007;78(8):1491-1504.
  3. Chava V. The effect of stress on periodontitis: A clinicobiochemical study. Journal of Indian Society of Periodontology. 2012;16(3):365.
  4. Reners M, et al. Stress and periodontal disease. International Journal of Dental Hygiene. 2007;5(4):199-204.
  5. Goyal S, et al. stress and periodontal disease: The link and logic!!. Industrial Psychiatry Journal. 2013;22(1):4.
  6. Gunepin M. Impact of chronic stress on periodontal health. Journal of Oral Medicine and Oral Surgery. 2018;24(1):44-50.

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